Provider Demographics
NPI:1831475805
Name:MILLENNIUM P.T. AND REHAB. P.C.
Entity Type:Organization
Organization Name:MILLENNIUM P.T. AND REHAB. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:DE MONTAGNAC
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-321-8910
Mailing Address - Street 1:4210 COLDEN ST
Mailing Address - Street 2:SUITE. 209
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-4845
Mailing Address - Country:US
Mailing Address - Phone:718-321-8910
Mailing Address - Fax:718-321-9022
Practice Address - Street 1:4210 COLDEN ST
Practice Address - Street 2:APT. 209
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-4845
Practice Address - Country:US
Practice Address - Phone:718-321-8910
Practice Address - Fax:718-321-9022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-22
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016579-1251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02285418Medicaid
NY04604Medicare PIN